The Coordination of United Nations Health Sector Support in Bangladesh: Necessary, Insufficient, and Misguided?

Abstract

The coordination of aid in countries that attract large sums of external resources from numerous donors remains a source of concern to recipient governments and the donor community. This concern has been reflected in demands for, and attempts by, the United Nations to improve the coordination of its operational activities. (1) Ideally, the propensity for UN coordination should have been facilitated by the fact that (1) UN organizations do not face the same pressures as their bilateral counterparts to situate their programs within the rubric of national political, economic, or diplomatic objectives; (2) UN organizations occupy a special niche within the development community as a function of their normative authority and perceived neutrality; (2) and (3) UN organizations were established as part of a system through which coordination could have been imposed by command. Such a system, however, has not evolved, and because coordination has remained elusive, the UN has been subject to external pressure from donor s to establish instruments that might facilitate improved coordination among its organizations. In this article, I assess the implementation of a series of global initiatives of the United Nations system designed to coordinate the operational activities of its member organizations--contrasting between the broad and well-intentioned global enterprises and the reality of their execution at the country level in Bangladesh. I describe the rationale and intent of each of the mechanisms, and the nature of their adoption in Bangladesh, and evaluate them against a series of criteria. The evaluative framework, which is further elaborated elsewhere, (3) builds on principles adopted by the Development Assistance Committee of the Organization for Economic Cooperation and Development (OECD) along with the World Bank, International Monetary Fund (IMF), and UN Development Programme (UNDP). These principles place salience on recipient leadership and the provision of external support in such a manner that bolsters the capacity of recipients to undertake this role. Emphasis is placed on the extent to which these instrume nts impact the effectiveness of aid coordination in the health sector. An exploration of ownership, representation, and decisionmaking in relation to these mechanisms helps explain why the coordination activities have been largely ineffectual. As the organizations form part of a system theoretically conducive to coordination, an analysis of their failure to coordinate is instructive for the lessons it offers regarding coordination more generally. It also raises important questions in relation to future arrangements for global health governance. I base my findings on an in-depth, historical case study of health sector aid coordination in Bangladesh (1973-1997) carried out in 1996 and 1997. The methods, which are reported elsewhere, involved a stakeholder analysis, semistructured interviews with more than eighty officials, the administration of a semistructured questionnaire, and an exhaustive review of published and unpublished literature. (4) Although the mechanisms for UN system coordination continue to evolve (and perhaps improve), this does not detract from the need for rigorous and disinterested analysis of past practice. What follows relates to the specific case of Bangladesh, which was chosen because of its dependency on foreign assistance and the large number of multilateral organizations with operational programs in the health sector. While one would expect great variation among countries in relation to the effectiveness of UN coordination arrangements (reflecting context and the personal proclivities of key actors), the perverse incentives mitigating against coordination are globally institutionalized in the aid regime. The context of health sector aid coordination in Bangladesh was strongly conditioned by a consortium of donors led by the World Bank; nonetheless, the inter- and intraorganizational impediments retain universal significance. …